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J Shoulder Elbow Surg (2014) 23, 850-854

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Re-rupture rate of primarily repaired distal

biceps tendon injuries

John W. Hinchey, MD, Jessica G. Aronowitz, MD, Joaquin Sanchez-Sotelo, MD, PhD*,Bernard F. Morrey, MD

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA

Background: Distal biceps tendon rupture is a common injury, and primary repair results in excellent re-turn of function and strength. Complications resulting from distal biceps tendon repairs are well reported,but the incidence of re-ruptures has never been investigated.Methods: A search of the Mayo Clinic’s Medical/Surgical Index was performed, and all distal bicepstendon repairs from January 1981 through May 2009 were identified. All patients who completed 12months or more of follow-up were included. All charts were reviewed and patients contacted as necessaryto identify a re-rupture. We also investigated the situation causing the re-rupture.Results: We identified a total of 190 distal biceps tendon ruptures that underwent repair and met our in-clusion and exclusion criteria. Of the 190 repairs, 172 (90.5%) were performed by the Mayo modificationof the Boyd-Anderson 2-incision technique. Bilateral ruptures occurred in 13 patients (7.3%). Six primaryruptures (3.2%) occurred in women, 4 of the 6 being partial ruptures. Partial ruptures were found to bestatistically more common than complete ruptures in women (P ¼ .05). We identified 3 re-ruptures(1.5%), all occurring within 3 weeks of the index surgery.Conclusion: The re-rupture rate after primary repair of the distal biceps tendon is low at 1.5% and occurswithin 3 weeks of index repair. This appears to be due to patient compliance and excessive force placed onrepairs. We also found the incidence of women who sustain a distal biceps tendon tear to be 3.2%, withpartial tears being statistically more common than complete ruptures.Level of evidence: Level IV, Case Series, Treatment Study.� 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Distal biceps; biceps; repair; re-rupture; biceps failure

The incidence of distal biceps tendon ruptures is esti-mated to be 1.2 per 100,000 patients,22 with the peakincidence occurring in the fourth and fifth decades. Thepopulation sustaining this injury is predominantly male,

is study was provided by the Mayo Clinic Institutional

13-003860).

uests: Joaquin Sanchez-Sotelo, MD, PhD, Mayo Clinic,

SW, Rochester, MN 55905, USA.

ss: sanchezsotelo.joaquin@mayo.edu (J. Sanchez-Sotelo).

ee front matter � 2014 Journal of Shoulder and Elbow Surgery

/10.1016/j.jse.2014.02.006

and most occur in the dominant extremity.12,14,16,,21 Acomplete distal biceps tendon rupture is readily diagnosed,and repair has been shown to provide excellent relief ofpain and return of strength postoperatively2,16 comparedwith nonoperative treatment,19 with multiple techniquesbeing reported for repair. In contrast to complete ruptures,partial tears of the distal biceps tendon are more difficultto diagnose but are a cause of antecubital pain and weak-ness with supination and flexion. The reports in the litera-ture on partial tears also support surgical treatment after

Board of Trustees.

Distal biceps tendon re-rupture rate 851

failed conservative management, leading to excellentresults.4,9,13,24

Common complications after repair are well reported inthe literature; the most common are lateral antebrachialcutaneous nerve injury, radial nerve injury, and heterotopicossification.5,12,15 Re-rupture after primary repair, of com-plete and partial tears, is a potential complication that haslittle mention in the current literature. We are not aware ofany published investigation dedicated to ascertain the fail-ure rate in a large cohort of surgically treated patients. Theprimary goals of this study were to report on the failure ratefor primarily repaired partial and complete distal bicepstendon ruptures at a single institution, to document the finaloutcome of such patients, and if possible to identify whenthe risk for re-rupture is greatest. A secondary goal was tobetter define the percentage of women that this injury af-fects. To our knowledge, these have never been described inthe literature.

Materials and methods

A search of the medical-surgical patient database was performedto identify all patients who underwent distal biceps repair by anysurgeon at our institution between the dates of January 1, 1981,and May 31, 2009. All surgical reports were reviewed along withfollow-up clinic notes. Exclusion criteria included the use of anallograft and a procedure that was a revision. Additional exclusioncriteria included patients younger than 18 years at time of repair,initial tear due to an infection, surgery performed on an intra-muscular or intratendinous tear, incomplete follow-up, and patientunwilling or unable to participate.

A minimum follow-up of 12 months was required to beincluded in the study. Surveillance consisted of a repeated ex-amination by a physician at our institution or elsewhere. Thosewithout adequate documentation were contacted personally by thejunior investigator, who did not participate in any of the surgeries;both phone verbal consent and HIPAA (U.S. Health InsurancePortability and Accountability Act) authorization forms wereobtained from all patients with whom direct communication wasnecessary. The contacted patients were asked if they had experi-enced a re-rupture of the distal biceps tendon or had any repeatedsurgery performed on the elbow, for any cause, at an outsideinstitution.

Demographic information included sex, age at surgery, date ofsurgery, type of tear (i.e., partial or complete on the basis ofoperative reports), technique of repair, and documented compli-cations, specifically assessing for re-rupture and how it was treated.

The postoperative management varied throughout the studybecause of the long period included in the study and the number ofsurgeons involved. In the earlier years, patients were treated withcasting for 4 to 6 weeks postoperatively and then began range ofmotion per the individual surgeon’s protocol. This evolved overtime to a more aggressive rehabilitation protocol allowing patientsto actively and actively assisted move the elbow almost immedi-ately after surgery. Therefore, it was difficult to correlate thepostoperative rehabilitation protocol to outcomes or complica-tions. The one consistent feature of all the postoperative protocolswas that the patients were instructed in non–weight bearing of theoperative extremity for 6 to 8 weeks postoperatively.

Results

The database search returned a total of 234 distal bicepsrepairs in 219 patients. All patients who underwent distalbiceps repair for either a complete or partial tear wereincluded in this investigation. Five biceps repairs in 5patients were excluded because of supplemental use of anallograft. Also excluded were 36 biceps repairs in 34patients because of inadequate follow-up in spite of at least3 attempts to contact the patient in each instance. In addi-tion, 3 patients were deceased from unrelated causes andexcluded from this report.

The remaining 177 patients with a mean age of 48 years(range, 30-83 years) with 190 distal biceps rupturesconstituted the study population. Of the 177 patients whomet inclusion criteria, adequate follow-up of 12 months ormore was identified in 150; therefore, only 27 patients hadfollow-up conducted by phone interview. One of the 13bilateral repairs was performed simultaneously in the sameanesthetic setting, whereas the others were sustained andrepaired on separate occasions. There were 5 women with 6ruptures. Follow-up ranged from 12 to 321 months, with amean follow-up of almost 9 years (106 months).

All repairs were performed by consultant surgeons whoare board certified/eligible in orthopedics and trained inelbow surgery. A total of 15 different surgeons wereincluded in the study; 4 surgeons performed 158 of therepairs (83%). Of the 190 repairs, 172 (90.5%) wererepaired by the Mayo modification of the Boyd-Anderson2-incision technique (Fig. 1), as described by Morrey et alin 1985.16 Seventeen (9%) of the tears (all partial) wererepaired by a single-incision suture technique, with a singledorsal-lateral incision,13 and one (0.5%) was repaired withan endobutton technique.23 There were 131 complete rup-tures of the distal biceps tendon and 59 partial tears. Themodified Boyd-Anderson 2-incision technique was used forall complete tears except one and for all partial tears, otherthan the 17 repaired with a single dorsal-lateral incision.The only endobutton repair was used for a complete tear.

Complications

There were 29 (15%) total complications among those 190cases with completed follow-up not including re-ruptures.Of those, 9 were temporary radial nerve palsies, all ofwhich resolved; 2 patients had continued pain requiringd�ebridement; 3 patients had heterotopic ossification after arepair by the Mayo modified 2-incision technique thatrequired resection; 9 patients had temporary lateral ante-brachial cutaneous nerve palsies, all of which completelyresolved; 1 patient had reflex sympathetic dystrophy, whichalso completely resolved; and 5 patients had wound com-plications (1 deep infection, 4 superficial complications). Atotal of 8 of the 29 complications required repeated surgery(2, d�ebridement of adhesions; 3, excision of heterotopicossification; and 3, d�ebridement of the wound secondary to

Figure 1 Technique of instrument passage around the radius asdescribed in the Mayo modification. (By permission of MayoFoundation for Medical Education and Research. All rightsreserved.)

852 J.W. Hinchey et al.

infection). Of note, there was one re-injury in a 57-year-oldparaplegic man who underwent primary 2-incision repairand sustained a fall out of his wheelchair within 1 week ofsurgery. This fall caused a rupture at the myotendinousjunction, not at the prior surgical insertion site, thatnecessitated further surgical repair.

A total of 3 re-ruptures (1.5%) of primary repairs wereidentified from the 190 primary repairs investigated. All re-ruptures involved repairs with the Mayo modified Boyd-Anderson 2-incision technique. They all occurred, andunderwent repeated repair, within 3 weeks of the indexsurgery. The repeated repairs were all performed by theoriginal board certified/eligible consultant surgeon at ourinstitution. These 3 cases are briefly summarized.

Re-rupture No. 1 occurred in a 52-year-old man. Aftercompletion of his left distal biceps repair, he was beingawoken from general anesthesia and had a violent episodeduring his arousal and forcefully extended his arm. At thattime, a ‘‘pop’’ was heard, and examination showed that hehad a recurrent deformity. He was immediately placed backunder general anesthesia and the repair was repeated, afterwhich he had an uneventful postoperative course. At 38months postoperatively, the patient reported no issues.

Re-rupture No. 2 took place in a 45-year-old man whobegan to shovel snow using his right operative extremity,against medical advice, within 7 days postoperatively. Heunderwent revision repair 14 days after the index surgeryand was casted for 3 to 4 weeks because of his previousnoncompliance with postoperative restrictions. He wasobserved for 63 months after the revision and had excellentactive motion and use of the extremity.

Re-rupture No. 3 occurred in a 24-year-old man whounderwent a right distal biceps repair and was progressingwell postoperatively until he had an episode of ‘‘violent

sneezing’’ in which he actively and suddenly contracted hisoperative biceps 2 weeks after surgery. He immediatelynoticed pain and deformity in his elbow and presented forevaluation. He was found to have a re-rupture (Fig. 2) andunderwent revision surgery at postoperative day 20. Afterthe revision repair, he sustained a radial nerve palsy, whichresolved without residual deficit. He was observed for atotal of 14 months postoperatively and was happy with hisoutcome at final follow-up.

Discussion

In 2000, Kelly et al12 discussed complications of repairswith a modified 2-incision technique. Since that article,many authors have discussed their outcomes of distal bi-ceps repairs by multiple different methods of repair withmention of complications including re-rupture,5,12,15 butnone have reported the incidence of re-rupture in a largeseries of patients. Most of the reports of re-rupture are casereports or case series.

Cohen7 discussed complications being due to inadequateinitial attachment, patient noncompliance in the earlypostoperative period, or excessive tension on the repair.Mark Morrey et al17 showed that repairs performed in highflexion greater than 60� perform well with a low rate ofcomplications including only one re-injury (this patient isincluded in our series as the re-injury in the paraplegicpatient).1 These findings show that repairs, even withconsiderable tension, are well tolerated.

In 2005, Cheung et al6 reported on a series of 21 patientswho underwent Mayo modified Boyd-Anderson 2-incisionrepair with an immediate range of motion protocol andfound one re-rupture. This was attributed to ‘‘noncompli-ance’’ as the patient admitted to doing ‘‘a high-demandactivity.’’ Other authors have reported failures of suturerepair by the modified Boyd-Anderson technique. Bissonet al3 described a suture rupture 5 days postoperativelycausing the need for repeated repair but did not give detailsof the event causing the rupture. This was the only re-rupture of 45 cases they reported. Katolik et al11

described in their case report a repair failure 3 days post-operatively due to ‘‘noncompliance’’ as the patient liftedhis suitcase with his operative extremity.

There are multiple case reports and descriptions of repairfailures of endobutton techniques. Naidu,18 in 2010, shared acase of endobutton repair in which it loosened and theinterference screw had backed out into the soft tissues. Thiswas revisedwith an endobutton in a different position. A casereport by Desai8 discussed another endobutton failure due toa fall on ice 7 days postoperatively. Intraoperatively, thesuture was found to have failed, and the tendon retracted.This was also revised with another endobutton for repair.Peeters et al20 reported on their outcomes in 26 patientsall repaired with endobuttons. They described 3 cases of

Figure 2 (A) Magnetic resonance image shows postsurgical changes of radial tuberosity from index repair without tendinous attachment.(B) Magnetic resonance image shows proximal distal biceps retraction.

Distal biceps tendon re-rupture rate 853

malpositioning of the endobutton postoperatively, with onlyone of them showing signs and symptoms suggesting failedreattachment, but no further procedures were performed onthis case. It was unknown if the malpositioning was presentimmediately postoperatively or occurred during the post-operative course. A report of a proximal radius fracturethrough one of the drill holes used for repair was describedby Badia1 after the patient sustained a fall during the earlypostoperative period.

A 2011 level I investigation by Grewal et al10 comparedthe outcomes of single- vs double-incision techniques. Inthis study, 90 patients underwent an acute repair, with 4re-ruptures reported. All of the repeated injuries were dueto ‘‘noncompliance or reinjury during the early post-operative period,’’ which is in alignment with the findingsof our study.

This study describes the largest cohort of patients whohave undergone a primary repair of a distal biceps rupture.We found 3 re-ruptures (1.5%) in the 190 repaired. All thefailures occurred with the use of a Mayo modified Boyd-Anderson 2-incision suture repair. Also, we had a total of 6 of190 distal biceps ruptures that occurred in women (3.2%).One of these women sustained bilateral distal biceps rup-tures. Four of the 6 injuries in women were partial injuries.Partial ruptures occurred statistically more frequently inwomen than in men (P ¼ .05). Thirteen patients (12 men,1 woman) sustained bilateral injuries (7.3%).

Strengths of our study are the large size of the patientpopulation and a relatively low rate of patients lost tofollow-up (19%). We have a long length of follow-upaveraging approximately 9 years (106 months) that pro-vides information on possible late re-rupture, which did notoccur in our experience. We also had a relatively homo-geneous surgical technique during this study period.

Our study does have weaknesses, some of which areinherent to the retrospective nature. We did have 42 patients(with 44 distal biceps ruptures) lost to follow-up who mayhave had complications, including re-rupture. In addition,

the postoperative protocol was varied among the studyperiod, which may have changed the outcomes.

Conclusion

This is the first description in the literature to investigatethe incidence of distal biceps repair failure after primaryrepair. We found that the re-rupture rate is 1.5%, andthese failures occurred in the immediate postoperativeperiod of 3 weeks entirely because of patient complianceand excessive force across the fresh repair. We alsodocument the incidence in women to be 3.2%, with astatistically increased likelihood of sustaining partialruptures. These findings, along with the 7.3% incidenceof bilateral injuries, have not been previously reported toour knowledge. Finally, because all re-ruptures occurredearly, the practical insight of this experience is to protectthe patient for at least 3 weeks or more before engage-ment in any kind of strenuous activity.

Disclaimer

Joaquin Sanchez-Sotelo receives consultancy fees androyalties from Stryker, Biomet, DePuy, and Zimmer.Bernard Morrey is Medical Director of Tenex Health; hereceives royalties from SBC.

References

1. Badia A, Sambandam SN, Khanchandani P. Proximal radial fracture

after revision of distal biceps tendon repair: a case report. J Shoulder

Elbow Surg 2007;16:E4-6. http://dx.doi.org/10.1016/j.jse.2005.12.013

854 J.W. Hinchey et al.

2. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps

brachii. Operative versus non-operative treatment. J Bone Joint Surg

Am 1985;67:414-7.

3. Bisson L, Moyer M, Lanighan K, Marzo J. Complications associated

with repair of a distal biceps rupture using the modified two incision

technique. J Shoulder Elbow Surg 2008;17(Suppl):67S-71S. http://dx.

doi.org/10.1016/j.jse.2007.04.008

4. Bourne MH, Morrey BF. Partial rupture of the distal biceps tendon.

Clin Orthop Relat Res 1991;(271):143-8.

5. Cain RA, Nydick JA, Stein MI, Williams BD, Polikandriotis JA,

Hess AV. Complications following distal biceps repair. J Hand Surg

Am 2012;37:2112-7. http://dx.doi.org/10.1016/j.jhsa.2012.06.022

6. Cheung EV, Lazarus M, Taranta M. Immediate range of motion after

distal biceps tendon repair. J Shoulder Elbow Surg 2005;14:516-8.

http://dx.doi.org/10.1016/j.jse.2004.12.003

7. Cohen MS. Complications of distal biceps tendon repairs. Sports

Med Arthrosc 2008;16:148-53. http://dx.doi.org/10.1097/JSA.

0b013e3181824eb0

8. Desai SS, Larkin BJ, Najibi S. Failed distal biceps tendon repair using

a single incision endobutton technique and its successful treatment:

case report. J Hand Surg Am 2010;35:1986-9. http://dx.doi.org/10.

1016/j.jhsa.2010.08.029

9. Frazier MS, Boardman MJ, Westland M, Imbriglia JE. Surgical

treatment of partial distal biceps tendon ruptures. J Hand Surg Am

2010;35:1111-4. http://dx.doi.org/10.1016/j.jhsa.2010.04.024

10. Grewal R, Athwal GS, MacDermid JC, Faber KJ, Drosdowech DS,

El-Hawary R, et al. Single versus double-incision technique for the

repair of acute distal biceps tendon ruptures: a randomized clinical

trial. J Bone Joint Surg Am 2012;94:1166-74. http://dx.doi.org/10.

2106/JBJS.K.00436

11. Katolik LI, Fernandez J, Cohen MS. Acute failure of distal biceps

reconstruction: a case report. J Shoulder Elbow Surg 2007;16:E10-2.

http://dx.doi.org/10.1016/j.jse.2006.09.012

12. Kelly EW, Morrey BF, O’Driscoll SW. Complications of repair of the

distal biceps tendon with the modified two-incision technique. J Bone

Joint Surg Am 2000;82:1575-81.

13. Kelly EW, Steinmann S, O’Driscoll SW. Surgical treatment of partial

distal biceps tendon ruptures through a single posterior incision.

J Shoulder Elbow Surg 2003;12:456-61. http://dx.doi.org/10.1016/

S1058-2746(03)00052-1

14. Morrey BF, editor. Master techniques in orthopaedic surgery: the elbow.

2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2002. p. 173-91.

15. Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia:

WB Saunders; 2000. p. 468-78.

16. Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal

tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg

Am 1985;67:418-21.

17. Morrey ME, Abdel MP, Sanchez-Sotelo J, Morrey BF. Primary

repair of retracted distal biceps tendon ruptures in extreme flexion.

J Shoulder Elbow Surg 2014;. http://dx.doi.org/10.1016/j.jse.2013.12.

030. accepted for publication.

18. Naidu SH. Interference screw failure in distal biceps endobutton

repair: case report. J Hand Surg Am 2010;35:1510-2. http://dx.doi.org/

10.1016/j.jhsa.2010.06.016

19. Nesterenko S, Domire ZJ, Morrey BF, Sanchez-Sotelo J. Elbow

strength and endurance in patients with a ruptured distal biceps

tendon. J Shoulder Elbow Surg 2010;19:184-9. http://dx.doi.org/10.

1016/j.jse.2009.06.001

20. Peeters T, Ching-Soon NG, Jansen N, Sneyers C, Declercq G,

Verstreken F. Functional outcome after repair of distal biceps tendon

ruptures using the endobutton technique. J Shoulder Elbow Surg 2009;

18:283-7. http://dx.doi.org/10.1016/j.jse.2008.10

21. Ramsey ML. Distal biceps tendon injuries: diagnosis and manage-

ment. J Am Acad Orthop Surg 1999;7:199-207.

22. Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, de-

mographics, and the effect of smoking. Clin Orthop 2002;404:275-83.

http://dx.doi.org/10.1097/00003086-200211000-00042

23. Sutton KN, Dodds SD, Ahmad AS, Sethi PM. Surgical treatment of

distal biceps rupture. J Am Acad Orthop Surg 2010;18:139-48.

24. Vardakas DG, Musgrave DS, Varitimidis SE, Goebel F,

Sotereanos DG. Partial rupture of the distal biceps tendon. J Shoulder

Elbow Surg 2001;10:377-9.